Physician Medical Director - LTSS

Humana

3d • Remote

About The Position

Become a part of our caring community and help us put health first The Long-term services and supports (LTSS) Medical Director's primary responsibility is the review of medical authorizations. This review determines the medical necessity of a given service, level of care, or medical item/supply. The Medical Director's work assignments involve moderately complex to complex issues. These issues require an in-depth evaluation of variable factors, relying on clinical experience of both medicine and social determinants of health. You have a current/active Florida license and be willing to work East Coast hours. Please see position requirements for licensing details. The Long-term services and supports (LTSS) Medical Director's primary responsibility is the review of medical authorizations. This review determines the medical necessity of a given service, level of care, or medical item/supply. The Medical Director's work assignments involve moderately complex to complex issues. These issues require an in-depth evaluation of variable factors, relying on clinical experience of both medicine and social determinants of health. You have a current/active Florida license and be willing to work East Coast hours. Please see position requirements for licensing details. The LTSS Reviewing Medical Director may occasionally speak with entities including contracted external physicians, provider groups, health care facilities, or community groups. The goal of these conversations is to gain an understanding of Humana processes, and to focus on collaborative business relationships, values-based care, population health, or disease or care management. Medical Directors support Humana values, and Humana's mission, throughout all activities. Use your skills to make an impact Responsibilities The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts. You support and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services. After completion of mentored training, daily work is performed. Enjoy working in a structured environment with expectations for consistency in thinking and authorship. Exercise independence in meeting departmental expectations and meets compliance timelines.

Requirements

• 5+ years of direct clinical patient care experience post residency or fellowship experience
• Must have a current and unrestricted License in Florida and able to obtain Licenses in Indiana, Virginia, Georgia, Michigan, and other LTSS Medicaid states
• MD or DO degree
• Current and ongoing Board Certification in an approved ABMS/AOA Medical Specialty
• 5+ years of established clinical experience
• Knowledge of the managed care industry including Medicare or Medicaid products
• Have interpretation skills with 5+ years of experience focusing on quality management, utilization management, discharge planning, rehabilitation services, and home health services
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements.
• LTSS medical management organizations, Skilled Nursing Facilities, Long-term Care Facilities, Hospice, PACE, or Home Health Agencies and experience, working with health insurance other healthcare providers, and patient interaction.
• Internal Medicine, Physiatry, Family Practice, Geriatrics, Pediatrics, or Hospitalist experience
• Previous Medicare, Medicaid, and Commercial with 5+ years of experience
• Long-term Services & Supports or LTC/SNF with 5+ years of experience

Responsibilities

• The Medical Director provides medical interpretation and determinations whether services provided by other healthcare professionals are in agreement with national guidelines, CMS requirements, Humana policies, clinical standards, and (in some cases) contracts.
• You support and collaborates with other team members, other departments, Humana colleagues and the Regional VP Health Services.
• After completion of mentored training, daily work is performed.
• Enjoy working in a structured environment with expectations for consistency in thinking and authorship.
• Exercise independence in meeting departmental expectations and meets compliance timelines.

Benefits

• Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Ph.D. or professional degree